Provider Demographics
NPI:1720171614
Name:GOLD, MYRA A (MPAS - PA-C)
Entity type:Individual
Prefix:
First Name:MYRA
Middle Name:A
Last Name:GOLD
Suffix:
Gender:F
Credentials:MPAS - PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19596 HUNT RD
Mailing Address - Street 2:
Mailing Address - City:STRONGSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44136-8333
Mailing Address - Country:US
Mailing Address - Phone:440-238-6544
Mailing Address - Fax:
Practice Address - Street 1:12301 SNOW RD
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44130-1002
Practice Address - Country:US
Practice Address - Phone:216-362-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH000456363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00785778Medicare PIN
OHPA27592Medicare PIN